Improving medication use in older adults: looking back to move forward
Authors: Lorenz Van der Linden
Journal: The Lancet Healthy Longevity (2023)

Daunt and colleagues1Daunt R Curtin D O'Mahony D Polypharmacy stewardship: a novel approach to tackle a major public health crisis.Lancet Healthy Longev. 2023; 4: e228-e235Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar highlight in their Personal View the unresolved need to improve upon the current status quo regarding polypharmacy management, particularly in those older than 65 years with multimorbidity. The harms of polypharmacy in older adults are well documented and have been the focus of multiple trials. Yet, as succinctly stated by Daunt and colleagues,1Daunt R Curtin D O'Mahony D Polypharmacy stewardship: a novel approach to tackle a major public health crisis.Lancet Healthy Longev. 2023; 4: e228-e235Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar to date, no reproducible, effective interventions have been found. Accordingly, Daunt and colleagues1Daunt R Curtin D O'Mahony D Polypharmacy stewardship: a novel approach to tackle a major public health crisis.Lancet Healthy Longev. 2023; 4: e228-e235Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar propose a multicomponent framework based on polypharmacy stewardship with seven core elements to ensure implementation in practice, including the buy-in of experts and managers. We should acknowledge that the inspiration for this model, antimicrobial stewardship, although effective in some specific circumstances, has been found wanting in its battle against the widespread, ever-increasing antimicrobial resistance.2O'Sullivan CE Antimicrobial stewardship failure: time for a new model.J Antimicrob Chemother. 2020; 75: 1087-1090Crossref PubMed Scopus (4) Google Scholar Moreover, the feasibility of such a centralised approach for polypharmacy, coordinated by an expert team, remains unclear. Conversely, one might rather recommend revaluating the current set of large, neutral, randomised controlled trials of medication reviews while acknowledging that some did show a meaningful benefit in clinical outcome.3Bulow C Clausen SS Lundh A Christensen M Medication review in hospitalised patients to reduce morbidity and mortality.Cochrane Database Syst Rev. 2023; 1CD008986PubMed Google Scholar Valuable lessons can still be learned from the positive trials in terms of the best possible design, setting, and trial outcomes. These lessons are particularly relevant because the proposal by Daunt and colleagues1Daunt R Curtin D O'Mahony D Polypharmacy stewardship: a novel approach to tackle a major public health crisis.Lancet Healthy Longev. 2023; 4: e228-e235Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar resembles the guideline of the American Geriatrics Society proposal from more than 10 years ago, which provided a framework for dealing with multimorbidity in older adults.4American Geriatrics Society Expert Panel on the Care of Older Adults with MultimorbidityGuiding principles for the care of older adults with multimorbidity: an approach for clinicians.J Am Geriatr Soc. 2012; 60: E1-25Crossref PubMed Scopus (472) Google Scholar Here, we should question why such previous frameworks and interventions did not convincingly result in meaningful improvement of clinical outcome. These aspects come to mind: low protocol fidelity, a singular focus on medication use, low downstream implementation, and being underpowered for relevant clinical outcomes.3Bulow C Clausen SS Lundh A Christensen M Medication review in hospitalised patients to reduce morbidity and mortality.Cochrane Database Syst Rev. 2023; 1CD008986PubMed Google Scholar Perhaps we could pursue other statistical approaches to establish benefit, such as the win ratio, which has been shown to be a useful measure in clinical trials that involve multiple outcomes.5Pocock SJ Ariti CA Collier TJ Wang D The win ratio: a new approach to the analysis of composite endpoints in clinical trials based on clinical priorities.Eur Heart J. 2012; 33: 176-182Crossref PubMed Scopus (278) Google Scholar By combining the multiple outcomes into a single measure, this metric can provide a clearer picture of the overall benefit of an intervention. Accordingly, such an approach might help to identify more efficiently the most effective interventions for managing polypharmacy in older adults with multimorbidity. In conclusion, the proposed framework by Daunt and colleagues1Daunt R Curtin D O'Mahony D Polypharmacy stewardship: a novel approach to tackle a major public health crisis.Lancet Healthy Longev. 2023; 4: e228-e235Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar is a welcome addition to the ongoing discussion on managing polypharmacy in older adults with multimorbidity. However, we also have to consider the multitude of neutral trials and build on past proposals to develop the most effective interventions. I declare no competing interests. Polypharmacy stewardship: a novel approach to tackle a major public health crisisWith growing global concern regarding medication-related harm, WHO launched a global patient safety challenge, Medication Without Harm, in March, 2017. Multimorbidity, polypharmacy, and fragmented health care (ie, patients attending appointments with multiple physicians in various health-care settings) are key drivers of medication-related harm, which can result in negative functional outcomes, high rates of hospitalisation, and excess morbidity and mortality, particularly in patients with frailty older than 75 years. Full-Text PDF Open Access